Insurance Claim Attestation

INSURANCE CLAIM ATTESTATION

Claimant / Insured Information

Date of Birth:

Policy Details

Coverage Amount:    Deductible:    Premium:

Policy Period From:    To:

Claim Details

Date of Loss:    Time of Loss:

Property Occupied at Time of Loss: Yes No    Police Notified: Yes No

Coverage and Limits

Liability    Limit:

Collision    Limit:

Comprehensive    Limit:

Personal Injury Protection    Limit:

Uninsured/Underinsured Motorist    Limit:

Property Damage    Limit:

Other:

Exclusions and Acknowledgements

The claimant acknowledges that coverage is subject to the terms, conditions, endorsements and exclusions of the policy identified above. Typical exclusions include, without limitation, loss resulting from:

• Intentional acts, fraud, or criminal conduct by the insured;
• Wear and tear, gradual deterioration, or lack of maintenance;
• Losses excluded by specific policy endorsements (including business pursuits where not covered);
• Losses arising from nuclear hazard, war, or government action where excluded by the policy;
• Consequential, incidental or punitive damages unless expressly provided by endorsement.

I acknowledge that I have read and understand the standard exclusions above and any applicable endorsements to the policy.

Beneficiary Designation

Beneficiary Name:

Documentation Checklist

Police report

Photographs of damage/loss

Repair estimate(s)

Receipts or proof of purchase

Proof of ownership or title

Witness statement(s)

Declaration and Attestation

I, the undersigned claimant, hereby declare and attest that the information provided in this Insurance Claim Attestation is true, complete and correct to the best of my knowledge. I understand that submission of false or materially misleading information, or omission of material facts, may constitute fraud and may result in denial of coverage, rescission of the policy, civil liability, or criminal prosecution under applicable law.

I authorize the insurer and its authorized representatives to investigate and obtain records, statements and other information relevant to this claim, including but not limited to medical records, repair estimates, photographs, and law enforcement reports. I further authorize release of information necessary to process this claim to reinsurers, authorized adjusters, and other parties as required by the policy.

I agree to cooperate with reasonable requests for documentation and to submit to examinations under oath if requested. I acknowledge that settlement of this claim is subject to policy terms, conditions, endorsements, deductibles and applicable laws.

By signing below I certify under penalty of perjury that the foregoing is true and correct.

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